What works in reducing health inequalities

1. What works in reducing health inequalities Sally Macintyre sally@sphsu.mrc.ac.uk

2. What works? It is important to note a distinction between two questions: • does it work to improve health? • does it work to reduce health inequalities?

3. Because • no effect on health inequalities if all SES groups benefit equally • increase health inequalities if the rich benefit more • reduce health inequalities if the poor benefit more An intervention which, in general, works (e.g. dental health education) might have

4. More advantaged groups More advantaged groups find it easier, because of better access to resources : • time • finance • coping skills • literacy • health to take up health promotion advice and preventive services, and to benefit from these

5. Disadvantaged groups Less advantaged groups tend : • to be harder to reach • find it harder to change behaviour • to receive less benefit from lifestyle change or access to services

6. More likely to reduce inequalities • Structural changes in the environment • Legislative and regulatory controls • Fiscal policies • Income support • Reducing price barriers • Improving accessibility of services • Prioritising disadvantaged groups • Offering intensive support • Starting young

7. Less likely to reduce inequalities • Written materials • Campaigns reliant on people taking the initiative to opt in • Campaigns/messages designed for the whole population • Whole school health education approaches • Approaches which involve significant price or other barriers • Housing or regeneration programmes that raise housing costs • Information based campaigns

8. Inequalities in life chances are increasingThe toblerone society (up to 1980s) The 'toblerone' society

9. Increasing inequalities in life chances; The toblerone society 2021

10. Possibly competing goals Because the better off tend to gain more from social and public health policies, two public health goals: • improving population health • reducing health inequalities may sometimes conflict.

11. Possibly competing goals • Targeting the already advantaged may produce more aggregate health gain at relatively less cost. • Targeting the disadvantaged may produce less aggregate health gain and at greater cost. Value judgments will have to be made about the relative priority to be given to aggregate health gain or reducing inequalities.

12. Upstream/downstream: reducing inequalities in health may depend on reducing inequalities in life chances and life circumstances

13. To achieve equality of outcomes: Intervention ladder • Eliminate choice. • Restrict choice. • Guide choice through disincentives. • Guide choices through incentives. • Guide choices through changing the default policy. • Enable choice. • Provide information. • Do nothing or simply monitor the current situation.

14. Policy approaches: Universalism v Selectivity Universal (everyone gets the same) Selective/targeted/means tested (only the poorest receive the resources)

15. Progressive Universal Policies Universalism: all areas, families, individuals eligible for and provided with health promoting resources and opportunities (and protected from health damaging exposures) tempered by: Prioritisation: direct more resources to deprived or vulnerable areas, families, or individuals to compensate for greater needs and reverse inverse care/provision law and increase quality.

16. Key questions What priority should we give to: • Different age groups (e.g. early years, teenage transition, elderly etc • Different sectors (e.g. education, NHS, housing, employment etc) • Area based v individual/family based • Long term/short term outcomes • Different risk factors (e.g. smoking, alcohol, obesity, drugs etc.) • Different health burdens (e.g. CHD, cancers, mental health etc.)